Instead, Cantley did his physical therapy sessions in a dimly lit hallway on the sixth floor of the main hospital in what he described as "a miserable set of circumstances."

Robert "Spider" Cantley, of Twain Harte, poses for a photograph in front of Washington Hospital's new $42.7 million Center for Joint Replacement in Fremont, Calif., on Wednesday, March 20, 2013. Cantley a former Fremont resident of 40+ years underwent knee replacement surgery on both of his knees but was excluded from using the new center due to restricted doctor criteria established by the community hospital. (Anda Chu/Staff)
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ANDA CHU
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What Cantley and many other patients at the public hospital didn't know was that access to the new center, the only facility of its kind in the Bay Area, is restricted to just two orthopedic surgeons at the hospital -- the only ones on the Washington staff who met 24 criteria set by the hospital.

Those two doctors -- long the hospital's primary joint replacement specialists -- played a critical role in the creation of the lucrative new center, and one of them acknowledges he helped create the criteria that have excluded many of his fellow surgeons. Some of those surgeons and their patients are crying foul, saying the result is a "two-tier" system of care that favors wealthier patients and chosen doctors.

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"It is a community hospital, serving the public," Cantley, 78, told the publicly elected Washington Township Health Care District board at a meeting last month. "The public in no way, shape or form should be excluded from the new wing."

The arrangement has spurred a discrimination complaint to the state Department of Public Health on Sept. 4. Department officials said the complaint was still under investigation.

After repeated inquiries by this newspaper, a Washington official said last week the hospital will be looking at ways to allocate space in the center to all physicians.

In a Nov. 9 letter responding to an earlier letter from Cantley, Washington Township CEO Nancy Farber said the requirements for doctors to use the facility "help ensure the high-quality standards needed for the professional, clinical, research and education components of the (center)."

Cantley's physician, Dr. John Jaureguito, who has been on the medical staff at Washington for 18 years, said the arrangement means his patients get "second-class" treatment.

"Therapy is literally in the hallway," he said. "I've never come across anything like this before."

Jaureguito said all 10 orthopedic surgeons on Washington Hospital's medical staff who perform joint-replacement surgery thought they would relocate to the new center when it opened, until the criteria was distributed and most realized they wouldn't qualify. Jaureguito, for instance, is trained in sports medicine, rather than joint replacement as required, and performs 75 joint-replacement surgeries each year, below the criteria of 150 minimum.

"Is it unfair to surgeons? Yes. But it's a two-tiered system for patients," Jaureguito said. He said the criteria were "to weed out and eliminate us from taking part in using the facility to garner market share."

Restrictive criteria

A public agency in southern Alameda County, Washington Township opened the doors to its new facility with much ado last spring. Previously, all joint replacement patients were served in the hospital's Whitaker Pavilion, now slated for demolition before a new critical care building is constructed on the site.

Hospital officials said the $42.7 million building was paid for with hospital revenues, including revenue bonds, and donations from the nonprofit Washington Hospital Foundation, not tax dollars.

Anyone desiring access, however, would have to be a patient of a doctor who met 24 criteria. In addition to the 150-surgery minimum, at least 75 percent of the surgeries must be done at Washington Hospital, and at least 80 percent of the physician's total caseload must consist of joint replacements.

The only two surgeons who qualified, Dr. John Dearborn and Dr. Alexander Sah, received a five-year contract from the hospital to staff the center through May 2017 while maintaining their status as independent contractors, not employees, according to the contract. They were named co-medical directors for the Institute for Joint Restoration and Research.

Dearborn and Sah, who practice together, had earlier been instrumental in the planning for the center; the hospital district said it "would not have been possible" without them.

In an interview, Dearborn acknowledged that he also contributed to the creation of what he called the "very modest" criteria for doctors to use the center, but said, "I certainly wouldn't call it a two-tier system, but from the perspective of the surgery (I provide), the outcomes, we were running a two-tier unit before and trying to operate all in one place."

Historically, Dearborn and Sah have performed the majority of the hospital's joint-replacement surgeries -- about 89 percent of 1,141 total surgeries in the 2011-12 fiscal year -- and "patient volume has been increasing steadily since the institute opened," said Gisela Hernandez, a spokeswoman for the hospital, via email.

Though officials did not respond to repeated requests since Jan. 28 for the costs and revenues associated with the operation of the institute, Hernandez said in a Feb. 7 email that the institute "is providing a positive contribution to the hospital's bottom line; which ultimately helps the hospital continue to provide other programs and services that help us meet the community's medical and health care needs."

The average single joint-replacement surgery performed at Washington Hospital in 2011 cost nearly $160,000, more than twice the California average, state data show.

According to one of Dearborn's secretaries, neither he nor Sah accepts Medi-Cal or Alameda Alliance, which serve low-income residents, but typically carry lower reimbursement rates for doctors and hospitals than does Medicare.

Dearborn subsequently said their practice works with all insurance providers on a patient-by-patient basis and said he had a Medi-Cal patient on his schedule this month.

"The heart of it is, if a patient needs an operation and they are a good candidate for it, and they want us to do it, then I don't want there to be any barriers to it, and frankly I don't see any barriers to it, but I am sure my detractors do," he said.

Sah declined requests for an interview and deferred to Dearborn for comments.

Patient questions

Dr. Barry Rose said he and other orthopedic surgeons were shocked to learn of the requisites for institute participation at a quarterly Washington orthopedic staff meeting just two weeks before the center opened.

Rose said his patients are at risk because they are mixed in with the general patient populations and their therapy is conducted in a hallway used by infectious patients.

"I really think it sets up two tiers of patient care and I think it's wrong," Rose said. "I have lost some patients just based on the fact that they couldn't have surgery done by us and have their post-op care in the Center for Joint Replacement."

Washington officials said no evidence exists to indicate a higher risk of infection for joint-replacement patients at the main hospital.

No similar segregation of orthopedic patients exists at another public hospital, UCSF Medical Center, university officials said.

Dr. Tony Marzoni, executive vice president of Palo Alto Medical Foundation, said he has not seen a similar situation at other hospitals the medical group contracts with in the region, including Stanford Hospital & Clinics and public agencies El Camino Hospital and Sequoia Hospital.

Rose's patients still chafe at the policy that shut them out from the building.

Al Palmerino, 71, had a knee replaced Nov. 5 and said he wasn't aware he would be excluded until the day of his surgery. He said the policy made him question his support for district bond measures in the past, including the $186 million Measure Z passed Nov. 6.

"If the election were not the day after my surgery, I would have told everyone I could about the 'exclusive rights' to the new Joint Replacement Center to Dr. Dearborn's patients, and tried to dissuade any votes I could," Palmerino wrote in a hospital patient satisfaction survey.

"My doctor is qualified to do joint replacement in that hospital," Palmerino said in an interview. "What are they saying? Is he a second-rate doctor that doesn't have access to the same level of care for his patients?"